Provider Demographics
NPI:1659594224
Name:JOHN B. MARSHALL OPTOMETRIST PA
Entity Type:Organization
Organization Name:JOHN B. MARSHALL OPTOMETRIST PA
Other - Org Name:CAROLINA VISION ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:BRYAN
Authorized Official - Last Name:MARSHALL
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:919-732-5000
Mailing Address - Street 1:320 S CHURTON ST
Mailing Address - Street 2:
Mailing Address - City:HILLSBOROUGH
Mailing Address - State:NC
Mailing Address - Zip Code:27278-2509
Mailing Address - Country:US
Mailing Address - Phone:919-732-5000
Mailing Address - Fax:919-732-6855
Practice Address - Street 1:320 S CHURTON ST
Practice Address - Street 2:
Practice Address - City:HILLSBOROUGH
Practice Address - State:NC
Practice Address - Zip Code:27278-2509
Practice Address - Country:US
Practice Address - Phone:919-732-5000
Practice Address - Fax:919-732-6855
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-11
Last Update Date:2013-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC152W00000X
152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8909104Medicaid
NC152W00000XOtherTAXONOMY NUMBER
NC89013CTMedicaid
NC1296470001OtherPTAN
1296470001Medicare NSC
NC89013CTMedicaid
NC1296470001Medicare NSC